Endoscopic endonasal transsphenoidal surgery ......Neurosurg Focus / Volume 37 / October 2014 Checklist for endoscopic transsphenoidal surgery 3 majority of sellar-based lesions, sagittal

Neurosurg Focus / Volume 37 / October 2014

Neurosurg Focus 37 (4):E1, 2014

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©AANS, 2014

Several studies and worldwide initiatives have pre-viously established that intraoperative and periop-erative surgical checklists can minimize the inci-

dence of and prevent adverse events.5,9,15,16 Checklists for surgical procedures have been used on an international basis, and major reductions in morbidity and complica-tion rates have been achieved.6,12 Endoscopic endonasal surgery is highly dependent on the technology and instru-mentation that are integral to successful completion of the operation; the unavailability or dysfunction of any of these components may prevent the operation from being completed.4 Although surgical practices in endonasal en-doscopic surgery may vary greatly from one institution to another, we aimed to develop and pilot a working model for an intraoperative and perioperative checklist for the surgical treatment of pituitary tumors and other parasellar lesions. As endoscopic transsphenoidal surgery becomes more commonplace, and with its increasing complexity with respect to imaging, instrumentation, and endocri-

nological testing, it will probably become increasingly important to standardize this procedure by implementing an intraoperative checklist. The aims of this article were to outline the necessary considerations in the periopera-tive and intraoperative period prior to performing an en-doscopic endonasal approach to the sellar region and to describe our early experience with implementation of this surgical checklist.

Methods

A 3-part surgical checklist was devised, consisting of preoperative, intraoperative, and immediate postopera-tive sections. Data points for each section (summarized in Tables 1 and 2) were entered into a Web-based question-naire completed prior to and at the conclusion of endo-scopic endonasal skull base cases between August 2013 and June 2014. The online questionnaire was stored on a REDCAP database with password protection. All cases were treated by the same neurosurgical attending physi-cian; an otolaryngologist was present for the extended ap-proaches and for those requiring pedicled nasoseptal flap reconstruction.10 An extended timeout was conducted as part of the routine institutional surgical timeout. In addi-tion, a closeout portion was filled out at the end of each operation. All missing data, near misses, and periopera-tive errors were recorded and analyzed.

Endoscopic endonasal transsphenoidal surgery: implementation of an operative and perioperative checklist

Eisha Christian, M.D.,1 Brianna harris, M.D.,2 BozEna WroBEl, M.D.,2 anD GaBriEl zaDa, M.D.1

Departments of 1Neurosurgery and 2Otolaryngology, Head and Neck Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California

Endoscopic endonasal surgery relies heavily on specialized operative instrumentation and optimization of endo-crinological and other critical adjunctive intraoperative factors. Several studies and worldwide initiatives have previ-ously established that intraoperative and perioperative surgical checklists can minimize the incidence of and prevent adverse events. The aim of this article was to outline some of the most common considerations in the perioperative and intraoperative preparation for endoscopic endonasal transsphenoidal surgery. The authors implemented and pro-spectively evaluated a customized checklist at their institution in 25 endoscopic endonasal operations for a variety of sellar and skull base pathological entities. Although no major errors were detected, near misses pertaining primarily to missing components of surgical equipment or instruments were identified in 9 cases (36%). The considerations in the checklist provided in this article can serve as a basic template for further customization by centers performing endoscopic endonasal surgery, where their application may reduce the incidence of adverse or preventable errors as-sociated with surgical treatment of sellar and skull base lesions.(http://thejns.org/doi/abs/10.3171/2014.7.FOCUS14360)

KEy WorDs • endoscopic endonasal transsphenoidal surgery • skull base • endoscopy • pituitary neoplasms • checklist

Abbreviations used in this paper: ACTH = adrenocorticotropic hormone; BMP = basic metabolic panel; CBC = complete blood count; CD = Cushing’s disease; DDAVP = desmopressin; DI = dia-betes insipidus; FSH = follicle-stimulating hormone; GH = growth hormone; IGF-I = insulin-like growth factor–I; LH = luteinizing hormone; PRL = prolactin; PT = prothrombin time; PTT = partial thromboplastin time; TSH = thyroid-stimulating hormone; T4 = thyroxine.

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E. Christian et al.

2 Neurosurg Focus / Volume 37 / October 2014

The checklist is described in detail below to discuss the rationale behind each data point for each of the 3 sec-tions (preoperative, intraoperative, and immediate post-operative).

Preoperative Checklist Considerations (Table 1)History and Physical Examination. Prior to any con-

sideration for surgical intervention for pituitary adeno-mas or other sellar lesions, a focused patient history and detailed physical examination is required. In many cases, close collaboration with an endocrine specialist has al-ready been established. Detailed questions should always be asked to screen for Cushing’s disease (CD), acromeg-aly, fatigue, amenorrhea/galactorrhea, diminished libido, headache, visual loss, and other common symptoms and conditions associated with pituitary lesions. The preop-erative workup should also include ophthalmology, oto-laryngology, and endocrinology consultations as needed. Any patients harboring lesions in proximity to the optic apparatus should undergo formal visual testing, including visual field examination, by a neuroophthalmologist.

Laboratory Tests. Once a thorough history and physi-cal examination is completed, a routine preoperative labo-ratory panel that includes complete blood count (CBC), basic metabolic panel (BMP), prothrombin time (PT), partial thromboplastin time (PTT), and a type and screen should be obtained. In addition, an endocrine panel in-cluding prolactin (PRL), fasting morning cortisol, adreno-corticotropic hormone (ACTH), thyroid-stimulating hor-mone (TSH), free thyroxine (T4), growth hormone (GH), insulin-like growth factor–I (IGF-I), luteinizing hormone (LH), follicle-stimulating hormone (FSH) (in women), and free testosterone level (in men) should be part of the preoperative workup to identify any underlying hormonal

abnormality. One major consideration is to always ensure that a PRL level has been checked to avoid surgically treating a tumor that may be treatable with medications. A serum PRL level > 200 mg/L is typically diagnostic of a prolactinoma—these can be treated medically and will need to be identified prior to any surgical decision making. A serum PRL ≤ 200 mg/L in a patient with a macroadenoma points to pituitary stalk effect (decreased delivery of dopamine) rather than tumor secretion of PRL. Furthermore, one must always consider the potential for a phenomenon known as the hook effect, which may oc-cur in macroprolactinomas with extremely high levels of circulating PRL that may overwhelm the immunoassay and result in an artificially low or even normal PRL level. Dilution of serum samples must be specifically requested if suspicion of the hook effect is high enough.8,13,14

Of the major anterior pituitary hormonal axes, the two that typically require the most attention with regard to hormonal replacement prior to any intervention are the cortisol and thyroid axes. Medical replacement of hypo-functioning cortisol or thyroid axes should be implement-ed prior to any operation, typically in collaboration with an endocrinologist. A fasting morning cortisol test should be included in the preoperative workup and determines the need for stress-dose steroids in the operating room. Ideally, these levels should be measured between 8:00 and 9:00 a.m., when basal cortisol levels are at a peak. Appropriate stimulation testing, such as a cosyntrophin stimulation test, should be performed on an as-needed basis prior to any operation.8,13,14 Free T4 and TSH lev-els should also be checked prior to any intervention and treated according to the findings.

Imaging. Imaging should include an MRI study of the brain and sellar region with and without contrast. For the

TABLE 1: Preoperative checklist for endoscopic endonasal surgery*

Category Item Subitem

History & Physical Exam Laboratory Tests general labs CBC, BMP, PT/PTT, INR, type & screen

hormonal labs PRL, a.m. cortisol, ACTH, TSH, free T4, FSH, LH, free testosterone, GH, IGF-I

stimulation testing (as needed)PRL level dilutions (as needed to rule out hook effect)

Imaging MRI of sella w/ or w/o contrast; sagittal & coronal sequencesCT (as needed)MRA or CTA (as needed to rule out vascular lesion)MRI or CT for neuronavigation

Informed Consent procedure fat/fascial graft, lumbar draintumor bank/clinical trial

Meds corticosteroid, thyroid replacement therapy hydrocortisone, levothyroxinediscontinue blood thinners

Consultations endocrinologyneuroophthalmology (visual field testing)medical clearance

* CTA = CT angiography; INR = international normalized ratio; Meds = medications; MRA = MR angiography.



Checklist for endoscopic transsphenoidal surgery

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majority of sellar-based lesions, sagittal and coronal MRI sequences are preferred. A CT scan of the head obtained without contrast can also be helpful to detect intracra-nial calcification (i.e., with craniopharyngiomas) and is the preferred modality for patients who are unable to un-dergo MRI studies. A CT scan is also helpful for detail-ing the bony sphenoid sinus anatomy, including sphenoid septa, although an MRI study is also typically adequate for these purposes.17 Close attention should also be paid to the anatomy of the paranasal sinuses and configuration of any sphenoid sinus septations, degree of pneumatiza-tion of the sphenoid sinus, and morphology of the sel-lar floor. Furthermore, the course of the internal carotid arteries and intercarotid distance should always be con-sidered prior to planning any endonasal endoscopic skull base approach. Of course, any prior surgical history and methods for reconstruction must always play a major role in consideration of one surgical approach over another. Based on the planned operation, anatomy of the sellar floor and paranasal sinuses, and prior surgical history, the surgeon should plan according to whether intraoperative neuronavigation will be used, and this imaging should be performed ahead of time. We routinely use intraoperative neuronavigation in direct sellar approaches where a “flat” sellar floor is identified, in most extended approaches, and in all repeat operations.17

Informed Consent. As with any neurosurgical proce-dure, a candid discussion regarding the goals, risks, and benefits of as well as alternatives to surgery must take place with the patient as part of the informed consent process. The consent should address additional measures such as an abdominal or thigh tissue graft or lumbar drain, as needed. Additional consent forms for the purpose of tumor analysis (i.e., genomic or molecular studies) and storage, or other clinical research protocols, should also be obtained prior to starting the intervention.

Intraoperative Checklist (Table 2)Immediately prior to any endonasal endoscopic op-

eration for pituitary lesions, consideration of some or all of the following factors may reduce or even prevent the development of intraoperative complications, align the workflow goals of the surgical and operating room team, and ensure that all required equipment is available and functional before commencing the procedure.

Surgical Timeout and Medications. As with most surgical checklists, initial confirmation of the patient, procedure, and operative site are critical, in addition to a review of patient allergies and medications to be ad-ministered prior to and during the operation. Close com-munication with the anesthesiology team is imperative to assure that the patient receives the correct doses of medi-cations required. Perioperative antibiotics (most com-monly cefazolin) should be administered. Patients with evidence of hypocortisolemia should receive cortisol replacement (hydrocortisone or dexamethasone) during surgery, whereas at our institution, patients with normal preoperative cortisol levels who are undergoing selective adenomectomy do not undergo routine cortisol replace-ment. For patients with CD who are undergoing resec-

tion of a pituitary adenoma, the checklist must include a reminder that no corticosteroids are to be administered.

Imaging. The surgical team should ensure that the desired imaging is available and easily accessible in the operating room prior to starting the operation. For a ma-jority of sellar-based lesions, sagittal and coronal MRI studies are preferred. Close attention should again be paid to the anatomy of the paranasal sinuses and configuration of any sphenoid sinus septations, degree of pneumatiza-tion of the sphenoid sinus, and morphology of the sellar floor. Furthermore, the course of the internal carotid ar-teries and intercarotid distance should be reviewed prior to surgery. The degree of tumor invasion into surround-ing structures, proximity of critical blood vessels, and location of the normal pituitary gland and stalk relative to the lesion should be reviewed. If intraoperative neuro-navigation is to be used, the team should ensure that the correct image sequences and equipment is available.

Adjunctive Measures. Once the patient is intubated, the endotracheal tube should be mobilized to the left side of the mouth. An arterial line is preferred for blood pres-sure monitoring. An orogastric tube is inserted, which will be used once surgery is completed to suction any sur-gical fluid that was swallowed. Another alternative is to pack the oropharynx with moist throat packs or gauze. If throat packs are used, they will need to be included in the surgical count at the beginning and end of the operation. Additional adjunctive measures that require planning and discussion with the anesthesiology and nursing teams include insertion of a Foley catheter, which we use only for extended procedures, and plans for inserting a lumbar drain. If a lumbar drain is inserted prior to the operation, clear communication with the anesthesia team must take place to assure that the drain settings are optimized.

Positioning. The patient is placed in the supine posi-tion with the head mildly flexed and rotated approximate-ly 10° toward the surgeon, with the head elevated above the thorax to optimize venous outflow. Intraoperative neuronavigation can then be registered to verify accuracy. At this point, the nose is packed with lidocaine-soaked cottonoids or a nasal decongestant such as oxymetazo-line. The nose is then prepared with povidone-iodine or another cleansing agent after the cottonoids are removed. The abdomen (or lateral thigh) should also be prepared and draped for a potential fat and/or fascia graft. Any plans for a pedicled nasoseptal flap should be discussed prior to starting the operation.

Equipment. Prior to any operation, it is mandatory that the surgeon and operating team confirm that the sur-gical instruments and equipment necessary to perform the procedure are available and sterile. Endoscopic skull base surgery requires that each component of the visualiza-tion system, which includes the telescope, camera, light source, fiberoptic cable, and display monitor, functions in an ideal fashion. If any of these components are not work-ing properly, the ability to perform the operation may be compromised. This has been referred to as a “clock-gear” mechanism, in which the entire endoscopy setup relies heavily on each individual component.2 In addition to the


E. Christian et al.


endoscopy system, the surgeon should ensure that the cor-rect skull base and transsphenoidal instruments are avail-able, in addition to the sinus debrider, high-speed drill, lens irrigating systems, micro-Doppler instrument for carotid localization,7 and/or additional mechanical tumor resection devices such as the ultrasonic aspirator.

Surgical Terminus. Once surgery is completed and a sling dressing is in place, the throat packs must be re-moved. If an oral glucose tolerance test was used, the anesthesiologist will suction out gastric contents prior to extubation. Immediately following extubation and prior to transfer to the recovery room, visual status is always verified to ensure that no acute compression of the optic apparatus has occurred secondary to an expanding hema-toma or graft insertion.

Postoperative Checklist Considerations (Table 3)Postoperative Examination and Orders. Postopera-

tive care begins with an immediate neurological exami-

nation with attention to visual acuity and fields. Postop-erative orders should include screening parameters for diabetes insipidus (DI), which include checking sodium levels every 6–12 hours. In addition, the nursing staff should be instructed to send an immediate urine sample for specific gravity and sodium tests for urine output > 250 ml/hour for 2 consecutive hours. If a patient has low preoperative cortisol axis function, high-dose hydrocorti-sone should be tapered down to a physiological dose over the next week or so.

Postoperative Day 1 laboratory tests should include close monitoring for new hypocortisolemia in patients with normal preoperative hypothalamic-pituitary-adrenal axis function who were not given intraoperative cortico-steroids; this is often done by obtaining daily morning fasting cortisol levels and initiating cortisol replacement for patients with low values and/or symptoms consistent with hypocortisolemia. In patients with acromegaly, a fasting morning GH level should be obtained on postop-

TABLE 2: Intraoperative checklist for endoscopic endonasal surgery*


Surgical Timeout patient ID, procedure, allergies, medsMeds antibiotics Ancef, vancomycin

corticosteroids hydrocortisone, dexamethasoneImaging MRI of sella w/ or w/o contrast; sagittal & coronal sequences

displayed in ORAdjunctive Measures endotracheal tube positioning routine

radial arterial line routineorogastric tube or oral packing routinelumbar drain extended approachesFoley catheter extended approaches

Positioning head elevated above thoraxflexion/extension for extended approaches

Neuronavigation registration performed w/ good accuracyPreparation nasal Afrin, lidocaine w/ epinephrine, iodine prep

abdomen or thigh for fat/fascial harvestpedicled nasoseptal flap extended approaches

Equipment endoscopy system 0°, 30°, & 45° telescopescameralight source & fiberoptic cableHD monitorClearvision or other lens irrigatorrecording equipment

microscope as needed for backup sinus debridersinus & skull base instrumentsmicro-Dopplertumor resection instruments Nico Myriad, CUSA, SonoPetreconstruction materials DuraSeal, fibrin glue, Porex plate

Surgical Terminus removal of throat packs or OGTT suctioningpupillary/visual check (prior to leaving OR)

* CUSA = Cavitron ultrasonic surgical aspirator; HD = high definition; OGTT = oral glucose tolerance test; OR = operating room; prep = preparation.




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erative Days 1 and 2; levels < 2 ng/ml typically predict long-term remission, whereas higher levels are associ-ated with higher rates of recurrence.11 Additional labora-tory tests include cortisol levels every 6 hours in patients with CD and daily morning PRL levels for patients with prolactinomas.1,3 If early DI develops, we prefer to use subcutaneous desmopressin (DDAVP) initially, and then transition to oral or nasal spray DDAVP as needed, in an-ticipation of discharge planning.

Special Orders. Although nasal packing is not rou-tinely used, additional instructions include removal of nasal packing at any specified postoperative time point when used and specific lumbar drain management speci-fications. For standard pituitary adenomas, we typically obtain an MRI study of the sella 3 months after surgery. However, for nonadenomatous lesions or extended ap-proaches we often obtain postoperative imaging within 72 hours of surgery. A repeat sodium level, obtained on an outpatient basis, should be checked on or around post-operative Day 7 to evaluate for delayed hyponatremia.18 Discharge planning should include follow-up with the neurosurgeon, endocrinologist, and ophthalmologist.

ResultsWe surveyed a total of 25 patients (Table 4) with 16 en-

doscopic endonasal approaches for pituitary adenomas, 3 for Rathke cleft cysts, 1 arachnoid cyst, and 1 case of lym-phocytic hypophysitis. The checklist was also applied to additional anterior skull base endoscopic cases, including 3 anterior fossa CSF leak reconstructions and 1 clival chor-doma. Twenty-three cases were direct endoscopic trans-sphenoidal approaches and two were extended endonasal cases. We used nasoseptal flap reconstruction in 7 cases.

The checklist was readily adopted by nursing and anesthe-sia colleagues without any barriers to implementation.

Our preoperative checklist survey (Table 5) had no missed or incomplete sections. A majority of checkpoints in this section are part of our institutional preoperative checklist and therefore were redundant checkpoints. It is important to note that thyroid replacement and steroid therapy are not part of our institutional list and therefore might be missed or overlooked if not thoroughly reviewed before an operation.

During implementation of the intraoperative check-list (Table 6), no major surgical errors were identified.

TABLE 3: Postoperative checklist for endoscopic endonasal surgery*


Physical Exam general neurological examvisual acuity & fields

Laboratory Tests Ordered sodium levels every 6 or 12 hrs monitoring for DI if UOP >250 ml/hr for 2 consecutive hrs, send

immediate specific gravity & sodiumnext-day a.m. labs CD: cortisol level every 6 hrs

acromegaly: a.m. GH levelHPA axis monitoring: cortisol level every a.m.prolactinoma: PRL level every a.m.

Imaging MRI of sella w/ or w/o contrast; sagittal & coronal sequences either w/in 72 hrs or in 3 mosSpecial Orders lumbar drain specifications

set time for removal of nasal packing (if used)Meds antibiotics

hormone replacementDDAVP

Discharge Planning sodium level on postop Day 7follow-up w/ endocrinologist & ophthalmologist

* HPA = hypothalamic-pituitary-adrenal; UOP = urine output.

TABLE 4: Patient clinical data

Finding & Procedure No. of Patients

total 25diagnosis pituitary adenoma 16 Rathke cleft cyst 3 arachnoid cyst 1 lymphocytic hypophysitis 1 CSF leak repair 3 chordoma 1procedure standard endoscopic transsphenoidal 23 extended approach 2 lumbar drain (inserted prior to procedure) 1 abdominal fat graft (site prepped) 14 thigh graft (site prepped) 11 nasoseptal flap 7


E. Christian et al.


However, 9 missing surgical components (near misses) that could have delayed or impeded progress during surgery were identified. These items (Table 7) included missing neuronavigation setup/equipment, Clearvision or other lens irrigator, micro-Doppler, recording equipment, and selected endoscopic skull base instruments.

DiscussionWe implemented a standardized and customized peri-

operative checklist designed for endoscopic pituitary and skull base surgery. The checklist was successfully used in 25 nonconsecutive cases over a 9-month period as a pi-lot analysis. We aimed to share our early experience and the specifics of our checklist as we move toward routine implementation of the checklist in all endoscopic endo-nasal cases. In our experience, the preoperative checklist proved to be redundant with the institutional checklist ex-cept for the endocrinological workup. The checklist was most useful in ensuring that all necessary equipment was available and functional prior to commencement of the operation. Although no major errors were detected (e.g., failure to detect a prolactinoma prior to transsphenoidal pituitary operation), the checklist was valuable in identi-fying missing key components of the operation in 9 cases (36% of operations). This checklist is especially helpful for new operating room personnel or in institutions that are just beginning to use endoscopy.

The limitations of this pilot prospective study are its implementation in a single center by a single surgeon in a

nonconsecutive pattern. More widespread and consistent analysis following routine use of this checklist via a multi-institutional format will provide more valid information pertaining to the benefits of its adoption. Nevertheless, we believe that reporting the early results of this pilot analysis and sharing our experience with the customized checklist may facilitate this process and lead to more rap-id adoption of similar checklists worldwide.

TABLE 5: Preoperative checklist results*

Checklist Item No. of Patients

preop workup history & physical 25 basic labs (CBC, BMP) 25 coagulation studies (PTT, INR) 25 chest radiograph 25 EKG 25 pregnancy test 12 blood type & screen 25 blood available 8 PRL 17 a.m. cortisol 18 thyroid studies 18 IGF-I 15 consent 25 tumor bank consent 14meds blood thinners discontinued 7 thyroid replacement therapy 3 intraop steroids 6 antibiotics 25

* EKG = electrocardiogram.

TABLE 6: Intraoperative checklist*

Checklist Item No. of Patients

surgical start timeout 25 neuronavigation available 22 MRI available 22 CT 3 CTA/MRA 1surgical positioning & adjuncts endotracheal tube positioned/taped 25 Mayfield pins 18 head above thorax 25 leg squeezers/SCDs 25 radial artery line 25 Foley catheter 10 lumbar drain 3 OGTT 2 throat packs 23surgical prep Afrin in nasal cavity 25 Betadine prep 25 abdomen prepped 14 thigh prepped 11endoscopy equipment 0°, 30°, & 45° scopes 25 camera 25 light source/fiberoptic cable 25 HD monitor 25 Clearvision lens irrigation 23 recording 24surgical equipment sinus debrider 25 skull base instruments 24 micro-Doppler 23 tumor resection: Nico Myriad 2 FloSeal/hemostatic agent 6 reconstruction materials: DuraSeal/Duragen 3surgical terminus throat packs removed 23 vision checked 25 counts correct 25

* SCD = sequential compression device.




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ConclusionsA successful approach to pathological entities in

the sellar region begins in the preoperative period with a thorough workup and attention to the patient’s endo-crinological and visual function. Intraoperatively, ensur-ing availability and functionality of the right equipment, positioning, and any adjunctive measures is likely to op-timize workflow and improve patient outcomes. The con-siderations in the checklist provided in this review can serve as a basic tool for further customization by individ-uals performing endoscopic transsphenoidal or anterior skull base surgery, and the use of such tools may reduce the incidence of adverse or preventable errors associated with surgical treatment of sellar and skull base lesions.

Disclosure

The authors report no conflict of interest concerning the mate-rials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Christian, Wrobel, Zada. Acquisition of data: Christian, Wrobel, Zada. Analysis and interpretation of data: Christian, Zada. Drafting the article: Chris tian, Harris, Zada. Critically revising the article: Christian, Zada. Re -viewed submitted version of manuscript: Christian, Zada. Approved the final version of the manuscript on behalf of all authors: Christian. Study supervision: Zada.

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Manuscript submitted June 16, 2014.Accepted July 11, 2014.Please include this information when citing this paper: DOI:

10.3171/2014.7.FOCUS14360. Address correspondence to: Eisha Christian, M.D., 1200 N. State

St., Ste. 3300, Los Angeles, CA 90033. email: [email protected].

TABLE 7: Incomplete or missing components constituting “near misses”

Component No. of Cases

recording equipment 1neuronavigation 3Clearvision lens irrigation 2micro-Doppler 2skull base tray 1


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Endoscopic endonasal transsphenoidal surgery ......Neurosurg Focus / Volume 37 / October 2014 Checklist for endoscopic transsphenoidal surgery 3 majority of sellar-based lesions, sagittal